﻿<!DOCTYPE html>

<html lang="en" xmlns="http://www.w3.org/1999/xhtml">

<head>
    <meta charset="utf-8" />
    <title></title>
    <style type="text/css">
        * {
            margin: 0;
            padding: 0;
        }

        .wrapBox {
            width: 95%;
            margin: 0 auto;
        }

        body {
            font-family: SimSun !important;
            padding-top: 20px;
            padding-bottom: 50px;
        }

        p {
            margin: 0px;
            line-height: 140%;
        }

        footer {
            color: #333;
            font-size: 1.2rem;
            margin-bottom: 1.5rem;
            margin-right: 5%;
            margin-top: 1.2rem;
            text-align: right;
        }

        table,
        td {
            border: 1px solid #444;
            border-collapse: collapse;
            /* text-align: center; */
            height: 2rem;
            padding: 5px;
        }

        .classItem {
            overflow: hidden;
            width: 100%;
        }

        .classItem .itemLeft {
            float: left;
            width: 50%;
        }

        .classItem .itemCont {
            width: 50%;
            float: left;
            text-align: center;
        }

        .classItem .itemCont .lag {
            font-size: 18px;
        }

        .classItem .itemCont strong {
            display: block;
        }

        .classItem .itemInput {
            border: 2px solid;
            background: #F1F4FF;
            height: 50px;
            line-height: 50px;
            margin-top: 5px;
            width: 80%;
            float: right;
        }

        .classItem .itemInput label {
            width: 130px;
            font-size: 16px;
            background: #fff;
            font-weight: bold;
            text-align: center;
            display: block;
        }

        .classItem .itemInput label::before {
            content: '';
            height: 0;
            width: 10px;
            height: 10px;
            border: 1px solid;
            text-align: center;
            margin: 19px 0 -17px -16px;
        }

        .classItem .itemInput.cur label::before {
            background: #444;
        }


        table td {
            color: #000;
            font-size: 18px;
        }

        table .item2 {
            background: #B8CCE4;
            color: #000;
            font-size: 14px;
        }

        table .custStyle {
            background: #DCE6F1;
            color: #000;
            font-size: 14px;
        }

        table .mystyle {
            color: #000;
            font-size: 14px;
        }

        table .mystyle span {
            margin-left: 20px;
        }

        table .mystyle span::before {
            content: '';
            width: 10px;
            height: 10px;
            height: 0;
            margin: 3px 0 10px -13px;
            border: 1px solid;

        }

        table .mystyle span.cur::before {
            background: #000;
        }
    </style>
</head>

<body>
    <div class="wrapBox">
        <div class="classItem">
            <div class="itemLeft" style="width: 60%;">
                <div style="overflow:hidden">
                    <div class="itemCont" style="width: 40%;">
                        <img src="./logo.png" alt="" width="100">
                        <p>4221 WILSHIRE BLVD #308</p>
                        <p>LOS ANGELES, CA 90010</p>
                        <strong>华人部 213-351-1488</strong>
                    </div>
                    <div class="itemCont" style="width: 60%;">
                        <strong>coway-usa.com</strong>
                        <strong class="lag" style="margin-top:22px">中文服务中心：323-556-8452</strong>
                        <strong class="lag" style="margin-top:6px">English Customer Service：213-386-3033</strong>
                    </div>
                </div>
                <h1 style="text-align:center; margin-top: 8px;">RENTAL/PURCHASE APPLICATION FORM</h1>
            </div>
            <div class="itemLeft" style="width: 40%;">
                <div class="itemInput cur" style="margin-top: 15px;">
                    <label for="">Order No</label>
                    @Model.Data.OrderNo
                </div>
                <div class="itemInput">
                    <label for="">Referral No</label>
                </div>
            </div>
        </div>

        <table style=" margin-top: 1%; width: 100%;">
            <tr style="font-size: 1rem; background-color:#366092">
                <td style="text-align: center; color: #fff;" colspan="11">CUSTOMER INFORMATION</td>
            </tr>
            <tr>
                <td class="item2" style="width:200px">*RENTAL/PURCHASE TYPE</td>
                <td colspan="10" class="mystyle">
                    <span>NORMAL</span>
                    <span class="cur">CREDIT INQUIRY </span>
                    <span>NEW ORDER DISCOUNT(Order No: )</span>
                    <span>REORDER (Order No: )</span>
                </td>
            </tr>
            <tr>
                <td colspan="1" class="item2"> *FIRST NAME (AS IN ID)</td>
                <td colspan="2"></td>
                <td colspan="2" class="custStyle">*LAST NAME (AS IN I.D.)</td>
                <td colspan="6"></td>

            </tr>
            <tr>
                <td colspan="1" class="item2"> *SOCIAL SECURITY NUMBER</td>
                <td colspan="2">123 -111 -1111</td>
                <td colspan="2" class="custStyle"> *DATE OF BIRTH (mm/dd/yyyy)</td>
                <td colspan="6">2020/23/33</td>

            </tr>
            <tr>
                <td colspan="1" class="item2">E-MAIL ADDRESS</td>
                <td colspan="2"></td>
                <td colspan="2" class="custStyle">TAX ID / BUSINESS
                    REGISTRATION NUMBER</td>
                <td colspan="6"></td>

            </tr>
            <tr>
                <td colspan="1" rowspan="2" class="item2"> *LEGAL ADDRESS /RESIDENCE</td>
                <td colspan="1" style="width:50px" class="custStyle"> STREET</td>
                <td colspan="6"></td>
                <td colspan="2" class="custStyle"> APT #</td>
                <td colspan="1"></td>

            </tr>
            <tr>
                <td colspan="1" class="custStyle"> CITY</td>
                <td colspan="3"></td>
                <td colspan="1" class="custStyle"> STATE</td>
                <td colspan="2"></td>
                <td colspan="2" class="custStyle"> ZIP CODE</td>
                <td colspan="1"></td>
            </tr>


            <tr>
                <td colspan="1" rowspan="2" class="item2">BILLING ADDRESS</td>
                <td colspan="1" class="custStyle"> STREET</td>
                <td colspan="6"></td>
                <td colspan="2" class="custStyle"> APT #</td>
                <td colspan="1"></td>

            </tr>
            <tr>
                <td colspan="1" class="custStyle"> CITY</td>
                <td colspan="3"></td>
                <td colspan="1" class="custStyle"> STATE</td>
                <td colspan="2"></td>
                <td colspan="2" class="custStyle"> ZIP CODE</td>
                <td colspan="1"></td>
            </tr>

            <tr>
                <td colspan="1" class="item2"> HOME PHONE NO.</td>
                <td colspan="2">( ) - </td>
                <td colspan="2" class="custStyle"> MOBILE PHONE NO.</td>
                <td colspan="6">( ) - </td>

            </tr>
            <tr>
                <td colspan="1" class="item2"> NAME OF SALES REP.</td>
                <td colspan="2"></td>
                <td colspan="1" class="custStyle"> SALES REP.PHONE</td>
                <td colspan="3"></td>
                <td colspan="2" class="custStyle"> SALES REP.CODE</td>
                <td colspan="2"></td>
            </tr>
            <tr style="visibility:hidden;">
                <td style="height: 0; " width="200px"></td>
                <td style="height: 0; " width="75px"></td>
                <td style="height: 0; " width="225px"></td>
                <td style="height: 0; " width="75px"></td>
                <td style="height: 0; " width="125px"></td>
                <td style="height: 0; " width="75px"></td>
                <td style="height: 0; " width="25px"></td>
                <td style="height: 0; " width="25px"></td>
                <td style="height: 0; " width="75px"></td>
                <td style="height: 0; " width="25px"></td>
                <td style="height: 0; " width="125px"></td>
            </tr>
        </table>

        <table style=" margin-top: 1%; width: 100%;">
            <tr style="font-size: 1rem; background-color:#366092">
                <td style="text-align: center; color: #fff;" colspan="12">INSTALLATION DETAILS</td>
            </tr>

            <tr>
                <td class="item2">REQUEST DATE</td>
                <td colspan="10" class="mystyle">
                </td>
            </tr>
            <tr>
                <td colspan="1" class="item2"> *FIRST NAME (AS IN ID)</td>
                <td colspan="2"></td>
                <td colspan="2" class="custStyle">*LAST NAME (AS IN I.D.)</td>
                <td colspan="6"></td>
            </tr>

            <tr>
                <td colspan="1" rowspan="2" class="item2">
                    INSTALLATION ADDRESS<br>(If different from the above current
                    address)
                </td>
                <td colspan="1" class="custStyle"> STREET</td>
                <td colspan="6"></td>
                <td colspan="2" class="custStyle"> APT #</td>
                <td colspan="1"></td>

            </tr>
            <tr>
                <td colspan="1" class="custStyle"> CITY</td>
                <td colspan="3"></td>
                <td colspan="1" class="custStyle"> STATE</td>
                <td colspan="2"></td>
                <td colspan="2" class="custStyle"> ZIP CODE</td>
                <td colspan="1"></td>
            </tr>

            <tr>
                <td colspan="1" class="item2"> PHONE (HOME)</td>
                <td colspan="2">( ) - </td>
                <td colspan="2" class="custStyle"> MOBILE</td>
                <td colspan="6">( ) - </td>

            </tr>
            <tr>
                <td colspan="1" class="item2"> OPTION</td>
                <td colspan="2"> </td>
                <td colspan="2" class="custStyle"> MEMBERSHIP</td>
                <td colspan="6"> </td>
            </tr>
            <tr>
                <td class="item2">REMARKS</td>
                <td colspan="10" class="mystyle">
                </td>
            </tr>
            <tr style="visibility:hidden;">
                <td style="height: 0;" width="200px"></td>
                <td style="height: 0;" width="75px"></td>
                <td style="height: 0;" width="225px"></td>
                <td style="height: 0;" width="75px"></td>
                <td style="height: 0;" width="125px"></td>
                <td style="height: 0;" width="75px"></td>
                <td style="height: 0;" width="25px"></td>
                <td style="height: 0;" width="25px"></td>
                <td style="height: 0;" width="75px"></td>
                <td style="height: 0;" width="25px"></td>
                <td style="height: 0;" width="125px"></td>
            </tr>

        </table>

        <table style=" margin-top: 1%; width: 100%;">
            <tr style="font-size: 1rem; background-color:#366092">
                <td style="text-align: center; color: #fff;" colspan="12">INSTALLATION DETAILS</td>
            </tr>
            <tr>
                <td width="50px" style="text-align:center" class="item2">NO.</td>
                <td width="150px" class="item2">MODEL</td>
                <td width="100px" class="item2">QUANTITY</td>
                <td width="150px" class="item2">
                    CONTRACT DURATION
                    (RENTAL ONLY)
                </td>
                <td width="150px" class="item2">
                    REGISTRATION FEE
                    (RENTAL ONLY)
                </td>
                <td width="125px" class="item2">
                    MONTHLY RENT
                    (W/O TAX)
                </td>
                <td width="125px" class="item2">
                    SALES PRICE
                    (W/O TAX)
                </td>
                <td width="100px" class="item2">TAX</td>
                <td width="150px" class="item2">TOTAL (USD)</td>
            </tr>
            <tr>
                <td style="text-align:center">1</td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
            </tr>
            <tr>
                <td style="text-align:center">2</td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
            </tr>
            <tr>
                <td style="text-align:center">3</td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
                <td></td>
            </tr>
            <tr>
                <td colspan="8" class="item2" style="text-align: right;">GRAND TOTAL (USD)</td>
                <td></td>
            </tr>
            <tr>
                <td colspan="2" class="item2" style="text-align: left;">MONTHLY PAYMENT METHOD (RENTAL ONLY)</td>
                <td colspan="10"></td>
            </tr>
        </table>

        <table style=" margin-top: 1%; width: 100%;">
            <tr style="font-size: 1rem; background-color:#366092">
                <td style="text-align: center; color: #fff;" colspan="12">ACCEPTANCE AND APPROVAL</td>
            </tr>
            <tr>
                <td style="width: 100%;" colspan="12">
                    I am providing the information in this application to Coway USA Inc. to apply for Coway Rental/Sale
                    Account.
                    By applying this account, I authorize and agree that:
                    • Coway may furnish this and other information about me (even if application is denied) and my
                    account to create and update their records, and to provide me with service
                    and special offers.
                    • Coway may make inquires if it considers necessary (including requesting reports from consumer
                    reporting agencies and other sources) in evaluating my application, and
                    for purposes of reviewing, maintaining or collecting my account.
                    • If the application is approved, Coway will send agreement and set up a delivery date.
                    • The agreement includes an arbitration provision that may limit my rights unless I reject that
                    provision under the agreement’s instructions.
                    This application and the Agreement are governed by federal and California law. Federal law requires
                    Coway to obtain, verify and record information that identifies you when
                    you open an account. Coway will use your name, address, date of birth, and other information for
                    this purpose. Please, note that you must reside in the United States and be
                    18 years or older to apply.
                </td>
            </tr>
            <tr style=" background-color:#366092">
                <td style="text-align: center; color: #fff; width: 50%;">CUSTOMER</td>
                <td style="text-align: center; color: #fff; width: 50%;">SALES REPRESENTATIVE</td>
            </tr>
            <tr>
                <td style="text-align: center; color: #fff; width: 50%;" class="SIGNATURE">
                    <br>
                    <p><label for="">SIGNATURE:</label><span>
					<img src="" alt="" width="100">
					</span></p>
                    <p><label for=""> DATE :</label><span></span></p>
                    </br>
                </td>
                <td style="text-align: center; color: #fff; width: 50%;" class="SIGNATURE">
                    <br>
                    <p><label for="">SIGNATURE:</label><span></span></p>
                    <p><label for=""> DATE :</label><span></span></p>
                    </br>
                </td>
            </tr>
        </table>
    </div>

</body>

</html>

<style>
    .SIGNATURE p {
        overflow: hidden;
        margin: 10px;
    }

    .SIGNATURE label {
        color: #000;
        display: inline-block;
        width: 200px;
        text-align: left;
        float: left;
        font-size: 14px;
    }
</style>